OPINION; Why the Fuss Over the D.S.M.-5?

By SALLY L. SATEL, M.D.

Published: May 12, 2013

CORRECTION APPENDED

LATER this month, the American Psychiatric Association will unveil the fifth edition of its handbook of diagnoses, the Diagnostic and Statistical Manual of Mental Disorders. Fourteen years in the making, the D.S.M.-5 has been the subject of seemingly endless discussion.

The charges are familiar: the manual medicalizes garden-variety distress, leads doctors to prescribe unnecessary medications, serves as a cash cow for the association, and so forth.

But many critics overlook a surprising fact about the new D.S.M.: how little attention practicing psychiatrists will give to it.

There are dozens of revisions in the D.S.M. — among them, the elimination of a “bereavement exclusion” from major depressive disorder and the creation of binge eating disorder — but they won’t alter clinical practice much, if at all.

This is because psychiatrists tend to treat according to symptoms.

So why the fuss over D.S.M.-5? Because of the unwarranted clout that its diagnoses carry with the rest of society: They are the passports to insurance coverage, the tickets to disability benefits and many schools rely on them to determine special educational and behavioral services.

This is a problem because the D.S.M. is an imperfect guide to predicting what treatments will benefit patients most — a reality tied to the fact that psychiatric diagnoses are based on clinical appearances that tend to cluster, not on the mechanism behind the illness, as is the case with, say, bacterial pneumonia.

Simply naming a mental illness does not necessarily point the way to effective treatment. This is why patients often qualify for more than one diagnosis, and why many have poor responses to medications.

Psychiatric assessment is imprecise because the causal systems that drive mental illness are daunting. Dozens of genes contribute to the development of the disorders we call autism, schizophrenia, bipolar illness, severe depression and A.D.H.D. Two people with the same genetic predisposition to mental illness may manifest their conditions differently. Why? Because a patient’s clinical picture depends on a jumble of other factors, including childhood adversity, head trauma, life experience and simple chance.

None of this is news to the framers of the D.S.M.-5. In fact, many psychiatrists had hoped to revise the approach to classifying mental illness. Instead of beginning with categories based on symptom groupings (e.g., schizophrenia, bipolar disorder and panic disorder) and working backward to their neurobiological origins, many researchers wanted to base classification on underlying biology.

To this end, investigators have made promising inroads by defining basic functions like working memory and fear circuitry that are disrupted in people with mental illness. Yet they are not able to generate a taxonomy that links particular types of dysfunction to clinical phenomena.

This will most likely change as researchers learn more about genetics, brain circuitry and cognitive data to fashion better guides to what to prescribe for patients, and in terms of what new compounds to develop.

Meanwhile, the D.S.M. offers discrete categories. At the least, these provide a common language practitioners can use to discuss patients. What’s more, even the most refined biological therapies will work best when coupled with efforts to help patients change troubling habits and to explore the subjective experiences of illness.

In deference to this complexity, the D.S.M. cautions users against taking too literally the sharp boundaries between disorders and between illness and the normal difficulties of life. Unfortunately, however, key public institutions often disregard these caveats.

Insurance companies cover services only if there is a diagnosis. Yet, the suffering of a patient who doesn’t have the symptoms required to qualify for a diagnosis is no less real and no less worthy of professional attention.

While it is true that the D.S.M. generally affords physicians enough leeway to shoehorn patients into some kind of diagnostic cubby for billing purposes, this flexibility can also backfire. In the employment context, for example, new or broadened disorders will most likely spur an increase in accommodation requests under the Americans With Disabilities Act and claims under state workers’ compensation laws.

School districts also rely on the D.S.M. Conditions like autism, A.D.H.D. or conduct disorder must be diagnosed in students in order for them to qualify for special therapies.

Parents press physicians to give children diagnoses, falsely inflating numbers of those with autism and A.D.H.D. It makes more sense to provide therapeutic services based on a child’s degree of impairment at school, at home and with peers.

Diagnoses also figure in disability determination. The Social Security Administration, for example, requires physicians to make a diagnosis before it will consider a benefit claim. Here, the error is mistaking a diagnosis for a prognosis.

I recall Laura, a 50-year-old university secretary who lived with her ailing mother. She spoke of being “suffocated in that mausoleum of a house,” but when her mother died, instead of feeling liberated, she was immobilized for weeks, barely eating, contemplating suicide and sleeping most of the day.

Laura brought up the possibility of being declared disabled. And with a D.S.M.-5 diagnosis of “major depression,” she could have been. Thankfully, she was willing to try treatment first. Although she was still troubled, psychotherapy and an antidepressant enabled her to return to work. Had Laura obtained disability benefits instead, her occupational lifeline would have been severed, along with her sense of purpose, daily structure and opportunities for socializing. Her home would have seemed even more like a tomb.

The media will trumpet the release of the new D.S.M., but practicing psychiatrists will largely regard it as a nonevent. Unfortunately, the same cannot be said for other institutions — insurance companies, state and government agencies, and even the courts — which will continue to imbue the D.S.M. with a precision and an authority it does not have.

DRAWING (DRAWING BY KRIS MUKAI)

Correction May 19, 2013, Sunday

This article has been revised to reflect the following correction: An opinion essay last Sunday about the usefulness of the Diagnostic and Statistical Manual of Mental Disorders referred imprecisely to the use of the handbook in determining eligibility for special-education services. While many school districts rely on the D.S.M. for such assessments, it is not a federal requirement that a condition like autism, A.D.H.D. or conduct disorder be diagnosed for a child to qualify for special therapies.